Intro to Urinary Tract Infections

Question 1

What are the different parts to the upper urinary tract?

Answer 1

Kidneys
• Parenchyma
• Pelvicalyceal system

Ureters
• Pelvic-ureteric junction
• Ureter
• Vesico-ureteric junction

Question 2

What are the different parts to the lower urinary tract?

Answer 2

Bladder 
Bladder outflow tract 
• Bladder neck (intrinsic urethral sphincter)
• Prostate 
• External urethral sphincter/pelvic floor 
• Urethra 
• Urethral meatus 
• Foreskin

Question 3

What are different natures of renal diseases?

Answer 3

• Infection
• Inflammation
• Iatrogenic
• Neoplasia
• Trauma
• Vascular
• Hereditary

Question 4

Give an examples of renal infection

Answer 4

Pyelonephritis

Question 5

Give an examples of renal inflammation

Answer 5

Glomerulonephritis, tubulointerstitial nephritis

Question 6

Give an examples of iatrogenic renal disease

Answer 6

Nephrotoxicity, PCNL

Question 7

Give an examples of renal Neoplasia

Answer 7

Renal tumours, collecting system tumours

Question 8

Give an examples of renal trauma

Answer 8

Blunt trauma

Question 9

Give an examples of vascular renal disease

Answer 9

Atherosclerosis, hypertension, Diabetes

Question 10

Give an examples of hereditary renal disease

Answer 10

Polycystic kidney disease, nephrotic syndrome

Question 11

What is the typical presentation of renal disease?

Answer 11

• Pain
• Pyrexia
• Haematuria
• Proteinuria
• Pyuria (puss in urine)
• Mass on palpation
• Renal failure

Question 12

What is the definition of proteinuria?

Answer 12

Urinary protein excretion >150mg/day

Question 13

How many types of haematuria are there?

Answer 13

Two;
• Microscopic - only seen under a microscope
• Gross (or macroscopic)

Question 14

Define microscopic haematuria

Answer 14

Found by urinalysis or urine dipstick; chronic or persistent if 5 or > RBCs per high-power field

Question 15

Define oliguria

Answer 15

Urine output <0.5ml/kg/hour (low)

Question 16

Define Anuria

Answer 16

• Absolute anuria - No urine output

* Relative anuria - <100ml/24 hours

Question 17

Define polyuria

Answer 17

Urine output >3L/24 hours (high)

Question 18

Define nocturia

Answer 18

Waking up at night ≥1 occasion to micturate

Question 19

Define nocturnal polyuria

Answer 19

Nocturnal urine output > 1/3 of total urine output in 24 hours

Question 20

Name common symptoms of UTIs

Answer 20

• Dysuria (pain)
• Frequency of urination
• Suprapubic tenderness
• Urgency
• Polyuria
• Haematuria

Question 21

What are the five stages in acute kidney injury?

Answer 21

1. Risk
2. Injury
3. Failure
4. Loss
5. End-stage kidney disease

Question 22

Define the 1. Risk stage of acute kidney injury

Answer 22

• Increase in serum creatinine level (x1.5)
• Decrease in GFR by 25%
• UO < 0.5 mL/kg/h for 6hrs

Question 23

Define the 2. Injury stage of acute kidney injury

Answer 23

• Increase in serum creatinine level (x2)
• Decrease in GFR by 50%
• UO < 0.5mL/kg/h for 12hrs

Question 24

Define the 3. Failure stage of acute kidney injury

Answer 24

• Increase in serum creatinine (x3)
• Decrease in GFR by 75%
• UO < 0.3mL/kg/h for 24hrs, or anuria for 12hrs

Question 25

Define the 4. Loss stage of acute kidney injury

Answer 25

* Persistent acute renal failure | * Complete loss of kidney function > 4 weeks

Question 26

Define the 5. End-stage kidney disease stage of acute kidney injury

Answer 26

Complete loss of kidney function > 3 months

Question 27

What are the six functions of the kidney?

Answer 27

* Body fluid homeostasis * Electrolyte homeostasis * Acid-base homeostasis (excrete H and generate HCO3) * Regulation of vascular tone * Excretory (urea, drugs etc) * Endocrine functions

Question 28

What are the endocrine functions of the kidneys?

Answer 28

* Erythropoeitin * Vit D metabolism * Renin

Question 29

What are the symptoms and signs of chronic renal failure?

Answer 29

* Asymptomatic (found via blood and urine testing) * Tiredness * Anaemia * Oedema * High blood pressure * Bone pain due to renal bone disease ``` In advanced Renal failure: • Pruiritus • Nausea/vomiting • Dyspnoea • Pericarditis • Neuropathy • Coma ```

Question 30

Give an example of iatrogenic/trauma ureteric disease

Answer 30

Inadvertently cut or tied during hysterectomy or colon resection

Question 31

Give an example of ureteric neoplasia

Answer 31

* Transitional cell cancer (TCC) of ureter * TCC of bladder obstructing VUJ * Prostate cancer obstructing VUJ * Pelvic malignancy * Pelvic or para-aortic lymphadenopathy

Question 32

Give an example of hereditary ureteric disease

Answer 32

* Pelvic-ureteric junction (PUJ) obstruction | * Vesico-ureteric junction (VUJ) reflux

Question 33

Give an examples of causes of ureteric obstruction

Answer 33

* Intra-luminal (stone, blood blot) * Intra-mural (scar tissue, TCC) * Exrta-luminal (pelvic mass, lymph nodes)

Question 34

What is the typical presentation of ureteric disease?

Answer 34

* Pain (eg. renal colic) * Pyrexia * Haematuria * Palpable mass (ie. hydronephrosis) * Renal failure (only if bilateral obstruction or single functioning kidney)

Question 35

What is the typical presentation of bladder diseases?

Answer 35

* Pain (suprapubic) * Pyrexia * Haematuria * Lower urinary tract symptoms (LUTS) * Recurrent UTIs * Chronic urinary retention (due to bladder underactivity) * Urinary leak from vagina (i.e. vesico-vaginal fistula) * Pneumaturia (i.e. colo-vesical fistula)

Question 36

What are the lower urinary tract symptoms of bladder diseases?

Answer 36

* Storage LUTS (i.e. frequency, nocturia, urgency, urge incontinence) * Voiding LUTS (i.e. poor flow, intermittency, terminal dribbling) – due to underactive bladder * Incontinence (stress, urge, mixed, overflow, neurogenic, dribbling, etc.)

Question 37

Give examples of the different nature of bladder diseases and their causes

Answer 37

Infection - cystitis Inflammation - interstitial cystitis, colonic diverticulitis resulting in colo-vesical fistula Iatrogenic/Trauma - bladder rupture, bladder injury from hysterectomy (resulting in vesico-vaginal fistula) Neoplasia - TCC of bladder, squamous cell carcinoma of bladder Idiopathic - overactive bladder syndrome Degenerative - chronic urinary retention Neurological - neurogenic bladder dysfunction

Question 38

Describe the control of micturition

Answer 38

1) Cortical centre (bladder sensation and conscious inhibition of micturition) 2) Pons (micturition centre) 3) Sacral segments (S2-S4) (micturition reflex): • Relaxation of internal urethral sphincter (autonomic - sympathetic) • Relaxation of external urethral sphincter (somatic) • Contraction of detrusor muscle (autonomic – parasympathetic)

Question 39

What are possible causes of LUTS?

Answer 39

• Bladder pathology (OAB, UTI, interstitial cystitis, bladder cancer) • Bladder outflow obstruction • Pelvic floor dysfunction • Neurological causes (i.e. neurogenic bladder dysfunction): - Supra-pontine lesions (i.e. stroke, alzheimers, parkinsons) - Infra-pontine supra-sacral lesions (i.e. spinal cord injury, disc prolapse, spina bifida) - Infra-sacral (i.e. MS, diabetes, cauda equina compression) • Systemic disorders (i.e. chronic renal failure, cardiac failure, diabetes mellitus, diabetes insipidus)

Question 40

What are the two stages in the micturition cycle?

Answer 40

1. Storage (or filling) phase | 2. Voiding phase

Question 41

What are the different natures of bladder outflow tract diseases?

Answer 41

Infection/Inflammation - prostatitis, balanitis Iatrogenic/Trauma - pelvic floor damage after traumatic vaginal delivery or hysterectomy, urethral injury from catheterisation or pelvic fracture Neoplasia - prostate cancer, penile cancer Idiopathic - chronic pelvic pain syndrome ``` Obstruction: • Primary bladder neck obstruction • Benign prostatic enlargement (BPE) causing obstruction • Urethral stricture • Meatal stenosis • Phimosis ```

Question 42

What is the presentation on bladder outflow tract disease?

Answer 42

``` • Pain (suprapubic or perineal) • Pyrexia • Haematuria • Lower urinary tract symptoms (LUTS) - Voiding LUTS (i.e. hesitancy, intermittency, poor flow, terminal dribbling, incomplete bladder emptying) due to Bladder Outflow Obstruction (BOO) - Overflow incontinence (high-pressure chronic urinary retention) - Stress urinary incontinence • Recurrent UTIs • Acute urinary retention • Chronic urinary retention ```

Question 43

What is acute urinary retention?

Answer 43

Defined as painful inability to void with a palpable and percussible bladder • 500ml to 1L

Question 44

What are causes for acute urinary retention?

Answer 44

Main risk is Benign Prostatic Obstruction (BPO) but can also occur independently of BPO (i.e. UTI, urethral stricture, alcohol excess, post-op) For those with BPO, usually triggered by unrelated event (i.e. constipation, alcohol excess, post-op)

Question 45

What is the treatment of acute urinary retention?

Answer 45

* Immediate treatment is catheterisation | * Also treat underlying cause